I see things differently, but may be totally wrong... Robert I think your summary is right on, but not sure about the solution.
So insurance don't pay for something called a monitored anesthesia care code why will they will pay for a monitored "disassociative" anesthesia care code? When this care is being delivered without reimbursement why would they pay at all? I still find it even more befuddling that insurance companies are allowed to get away with any of this? The codes are not provider specific, so if you are meeting all the requirements outlined by monitored anesthesia care, why can't one bill it? I just don't see a new code helping this argument or the reimbursement.
Amy, I also disagree that defintions will change grumpy anesthesiologists minds or change credentialling in institutions.. Just seems to me, if I were "the king" of sedation credentialling, I would care less about what meds are being used and I would be more interested in the rescue systems in place, screening processes, discharge etc.. then the training, skills, and experience of the person providing the sedation..medication would be last. This all seems a bit backward to me. Credentialling a medication just seems illogical especially when I have far greater concerns about giving a child chloral hydrate and sending them home, then propofol..... (and the literature would support this concern as well, right?)
I think peds em is a leader in sedation and analgesia... but we are naive to think we own it or invented it.. I would guess that the profession that provides the most sedation and has a much longer history is dentistry... We have a voice, but it needs to be a collaborative one--alot we can learn from anesthesia, critical care, dentistry etc..... sorry if this is blasphemy!
Mick
--- On Wed, 11/23/11, Amy Baxter <[log in to unmask]> wrote:
From: Amy Baxter <[log in to unmask]>
Subject: Re: Ketamine Sedation Classification: Moderate vs Deep vs Dissociative?
To: [log in to unmask]
Date: Wednesday, November 23, 2011, 11:47 AM
Nice summary, Robert-
One additional reason why this debate is important is for patient pain
management. In many systems a very effective method of decreasing
procedural pain (ketamine) has been forbidden to practitioners who are
skilled in it (hospitalists, nurse practitioners) due to its definitional
effects (general anesthesia). The end result is often that patients who
could have had a painful bedside procedure performed with a small dose of
ketamine (wound vac, chest tube pulled) now are allowed only opioids or
benzos, or worst case both. Thus, adherence to the current guidelines
leads to a more dangerous situation.
The previous posts concur with the literature: ketamine is safer than
fentanyl/versed. I think it's a great point that we are the experts in
procedural sedation and ANALGESIA. The Society for Procedural Sedation's
research and articles like Steve Green's are important to support logical
guidelines for safety and credentialling. Since definitions dictate
hospital policy most places, the argument for re-defining ketamine into
its own class makes sense to facilitate policies that will let our
patients benefit from a fast, safe, effective drug. That said, I
personally think that nitrous is also deserving of its own training module
and credentialling pathways or module. All levels of sedation by
responsiveness don't carry the same levels of risk. We should balance the
risks with the benefits for our patients and advocate for policies and
definitions that make sense.
(And before anyone jumps on me, of COURSE everyone using either should be
able to bag, know the laryngospasm notch maneuver, and know where the code
button is. I just think qualifying to use ketamine or nitrous should be
less rigorous than credentialling for propofol.)
Amy Baxter MD
Pediatric Emergency Medicine Associates
404 371-1190
Robert Flood <[log in to unmask]> writes:
>Hi everyone:
>
>In reading this, I believe there is more agreement than disagreement:
>
>1) We agree that sedation is a continuum.
>2) We agree that when providing anything more than anxiolysis, the
>provider
>should be able to "rescue" an airway.
>3) We probably agree that some type of advanced airway skill should be
>documented in order to receive credentials to perform moderate and deep
>sedations.
>4) We should agree that adverse events, as well as quality of the
>sedations, should be followed by the OPPEs at your hospital.
>5) We probably agree that non-anesthesia physicians have become the true
>experts in procedural sedation in children, yet anesthesia (through the
>ASA) still has nearly all the authority over this field even though they
>really don't perform as often as the rest of us. WE ARE the EXPERTS in
>performing Procedural Sedation and Anesthesia in Children.
>6) We should agree that billing for sedations should be an important part
>of this discussion. We need to be able to bill and collect for both
>moderate and deep sedations. Unfortunately, only moderate sedations have
>billing codes for non-anesthesia sedation, and the only way to bill for
>deep sedations is by using modified anesthesia codes.
>7) What we disagree on is terminology, so here goes my opinion:
>
>-Ketamine is a very unique drug in that it provides a dissociative state.
>-Still, by the definition of the ASA, in the dissociative state, the
>patient often lacks "purposeful response following repeated or painful
>stimuli" so it does meet the current definition of "deep sedation" but
>rather "general anesthesia". So, it is obviously not "moderate sedation"
>using the current definitions.
>-Yet, unlike general anesthesia, the "protective airway reflexes" are
>usually preserved with ketamine, which is makes it quite unique when
>compare to propofol for instance.
>- The insurance providers only recognize two basic billing code types for
>ED physicians: 1) Moderate sedation EM codes, and 2) Deep sedation using
>modified anesthesia codes
>- So, unless we, as non-anesthesia providers, take over the "authority" of
>procedural sedation across the nation, there can be no additional billing
>codes developed that will allow another category of "dissociative
>procedural sedation". So I fully support the initiative to create a new
>category for ketamine since it quite unique, safe, and preferred by many
>physicians performing painful procedures.
>- Until this new definition can be recognized by the insurance companies,
>we need to consider sedations with ketamine as "deep sedations" and bill
>using modified anesthesia codes.
>
>Just my opinion.
>
>Have a great thanksgiving!
>
>Bob Flood
>Cardinal Glennon Children's Medical Center
>St. Louis, MO
>
>
>On Wed, Nov 23, 2011 at 6:52 AM, Michael Verive <[log in to unmask]> wrote:
>
>> Kevin,
>>
>> I can see your point, and understand your position. At a former
>hospital,
>> we non-anesthesiologists (including PICU and ER docs) were barred from
>> using ketamine for *any* sedation because it was a "dissociative
>> anesthetic", and only anesthesiologists were allowed to administer
>> anesthetics. We could give as much midazolam and fentanyl as we wanted.
>> Made no sense to me, as ketamine was less likely to cause profound
>> hypotension or respiratory depression. Luckily, the chair of
>anesthesia at
>> the time was let go, and the interim chair allowed us to use ketamine,
>> provided we could demonstrate that we had the knowledge and skills
>> necessary to use it safely. We did, and when the anesthesia department
>> hired a replacement, he reviewed our sedation protocols and had no
>concerns
>> about our use of ketamine.
>>
>> I agree with you - ketamine is different than the other agents we use.
>It
>> can produce deep sedation (and even anesthesia) while simultaneously
>> permitting adequate spontaneous ventilation, oxygenation, and preserves
>> (and even augments) cardiovascular tone. It doesn't produce the same
>> cardiorespiratory depression that other agents do, even as patients
>drift
>> along the ill-defined sedation-anesthesia continuum.
>>
>> However, when you *do* run into problems with ketamine, the advanced
>> airway skills needed to support the patient are the same skills needed
>to
>> support patients who lose their airways with other agents. And, in the
>> event of a ketamine shortage, you may have to use other agents anyway,
>so
>> why not get credentialled to provide procedural sedation, irrespective
>of
>> the agent used?
>>
>> We have two pediatric hospitalists at our institution, and are looking
>at
>> expanding the program to at least a third hospitalist, and are
>developing a
>> procedural sedation model using pediatric hospitalists as sedation
>> providers, so I can definitely "feel your pain". If your peds
>hospitalists
>> are PALS (or APLS or similar) certified, they already have demonstrated
>the
>> skills needed to maintain/secure the airway in most pediatric patients,
>so
>> hopefully you won't have much difficulty getting the needed
>certification.
>>
>> Consider getting your hospitalists credentialled to provide "procedural
>> sedation", including (but not limited to) ketamine. It might be a bit
>more
>> work, but your anesthesia department will be more likely to support you.
>>
>> Michael Verive
>>
>>
>>
>> --- On Wed, 11/23/11, Kevin Powell <[log in to unmask]> wrote:
>>
>> > From: Kevin Powell <[log in to unmask]>
>> > Subject: Re: Ketamine Sedation Classification: Moderate vs Deep vs
>> Dissociative?
>> > To: [log in to unmask]
>> > Date: Wednesday, November 23, 2011, 6:03 AM
>> > I also think we would agree on the
>> > vast majority of ideas around sedation,
>> > but the couple disagreements are crucial to a pediatric
>> > hospitalist.
>> >
>> > I agree that the levels of sedation are not distinct
>> > levels.
>> >
>> > I certainly agree that patients can easily get more sedated
>> > than intended. I
>> > would agree that dosing of meds is not linear, as in 2x
>> > more med is twice as
>> > sedated. My use of the jargon "linear" reflects my
>> > engineering/math
>> > background. I tried to clarify that jargon with "simple,
>> > single, linear."
>> > Perhaps the term "one-dimensional" would be clearer.
>> >
>> > Your claim that sedation is a continuum, and your repeated
>> > use of the term
>> > light and deep, reinforces that one-dimensional idea. It
>> > implies that there
>> > are only two directions that sedation can go, lighter or
>> > deeper, and that
>> > the sedation can be rated on a single scale from 1 (none)
>> > to 0 (general
>> > anesthesia). The current model (let's use the ASA 2002
>> > guidelines that
>> > changed the definitions, Anesthesiology 2002; 96:1004–17)
>> > created a scale
>> > which has milestones based on patient response to stimuli.
>> > But there were 3
>> > other scales in that model - based on maintenance of
>> > airway, spontaneous
>> > ventilation, and CV function.
>> >
>> > A one-dimensional approach implies that when depressed
>> > responsiveness is at
>> > a moderate level, then the other 3 variables are at similar
>> > points in their
>> > scales of 1 to 0. This is an oversimplification and
>> > ketamine is the best
>> > example of this. Ketamine achieves a much greater drop in
>> > responsiveness for
>> > the same risk of losing spontaneous ventilation, when
>> > compared to
>> > midaz/fentanyl. With repeated boluses ketamine can maintain
>> > the same deep
>> > level of change in responsiveness as pentobarbital does,
>> > but with a much
>> > lower risk of hypotension. Rather than a one-dimensional
>> > continuum, sedation
>> > with different agents is at least two dimensional, if not
>> > >4. (To the 4
>> > scales in the ASA guidelines I would add "probability of a
>> > bad outcome
>> > unless patient receives a skilled intervention." )
>> >
>> > Unfortunately, the one-dimensional model leads to equating
>> > procedural
>> > sedation with ketamine to deep sedation with propofol,
>> > based on change in
>> > responsiveness. Here again is where we disagree. In many
>> > hospitals where the
>> > chair of anesthesia makes the rules, that
>> > oversimplification of classifying
>> > ketamine as equal to propofol interferes with the
>> > credentialing of
>> > procedural sedation by pediatric hospitalists, who almost
>> > always want the
>> > child unresponsive to mild stimulation. The term
>> > "dissociative anesthetic"
>> > is a terminology to remediate this errant one-dimensional
>> > model.
>> >
>> > I agree with your claim that there currently is not a carve
>> > out for
>> > dissociative sedation. The term dissociative is only used
>> > once in the 2002
>> > guidelines, and is followed by a hedge returning to the one
>> > dimensional idea
>> > of a "level." That was an error in the 2002
>> > guidelines. That misconception
>> > has yet to be fixed. The articles cited in the original
>> > post of this thread
>> > continue to add to the literature trying to fix the
>> > problem. As I stated in
>> > my post, this issue is not perceived as a major stumbling
>> > block for some
>> > subspecialties such as intensivists. That perception may
>> > explain why the
>> > Society for Pediatric Sedation has not adequately addressed
>> > the issue after
>> > 9 years.
>> >
>> > Kevin
>> >
>> >
>> >
>> > -----Original Message-----
>> > From: Michael Verive [mailto:[log in to unmask]]
>> > Sent: Tuesday, November 22, 2011 8:13 PM
>> > To: [log in to unmask];
>> > Kevin Powell
>> > Subject: Re: Ketamine Sedation Classification: Moderate vs
>> > Deep vs
>> > Dissociative?
>> >
>> >
>> > Kevin,
>> >
>> > I think we agree more than disagree on this. I also
>> > agree that ketamine is
>> > relatively safe (and safer than fentanyl/midazolam when
>> > used to provide the
>> > same level of sedation).
>> >
>> > Sedation *is* a continuum, and I never suggested that it
>> > was linear, nor did
>> > I suggest that the "levels" of sedation were distinct
>> > levels. Sedation is
>> > not predictable, and patients can easily become more or
>> > less deeply sedated
>> > than intended. There is significant variation in
>> > patient response to
>> > ketamine (and other sedative/anesthetic agents), so even if
>> > you intend to
>> > produce a "light" dissociative state, you may find that
>> > patients often
>> > become more deeply sedated than intended, especially if you
>> > need to use
>> > multiple doses of ketamine.
>> >
>> > Regardless of the level of sedation intended (or what you
>> > want to call it),
>> > the sedation provider needs to be able to rescue patients
>> > who become more
>> > deeply sedated than intended. Credentialling for
>> > ketamine (which is
>> > typically used to produce a level of sedation in children
>> > that borders on
>> > general anesthesia) will probably need to be on the same
>> > level as propofol,
>> > which is also very safe when used by personnel skilled in
>> > titrating it and
>> > rescuing patients who become too deeply sedated.
>> >
>> > Michael J. Verive, MD, FAAP
>> > Medical Director - Pediatric Intensive Care
>> > St. Mary's Hospital for Women and Children
>> > 3700 Washington Ave
>> > Evansville, IN 47750
>> >
>> >
>> > For more information, send mail to [log in to unmask]
>> > with the message: info PED-EM-L
>> > The URL for the PED-EM-L Web Page is:
>> >
>> > http://listserv.brown.edu/ped-em-l.html
>> >
>>
>> For more information, send mail to [log in to unmask] with the
>> message: info PED-EM-L
>> The URL for the PED-EM-L Web Page is:
>> http://listserv.brown.edu/ped-em-l.html
>>
>
>For more information, send mail to [log in to unmask] with the
>message: info PED-EM-L
>The URL for the PED-EM-L Web Page is:
> http://listserv.brown.edu/ped-em-l.html
>
For more information, send mail to [log in to unmask] with the message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
http://listserv.brown.edu/ped-em-l.html
For more information, send mail to [log in to unmask] with the message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
http://listserv.brown.edu/ped-em-l.html